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address
3800 Delaware Avenue Suite 103 Kenmore, NY 14217
phone
716-289-7486
Email
info.chopewny@gmail.com
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Personal Information
Name
(Required)
First
Last
Date of Birth
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MM slash DD slash YYYY
Address
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Street Address
City
State / Province / Region
ZIP / Postal Code
Email
(Required)
Phone
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School / Employer
Grade / Program
Please indicate the presence of a developmental disability, if any (check all that apply):
Autism
Epilepsy/Seizure Disorder
Intellectual Disability
Learning Disability (e.g., dyslexia, dysgraphia)
Other Neurological Impairment
Undetermined Developmental Disability
Other
Pls indicate disability
Does the applicant have care coordination?
Yes
No
To help us best accommodate the applicant, please answer the following questions as accurately as possible.
What level of support is needed for the applicant to be successful?
Shared Support
1:1 Support
Other
Does the applicant require the assistance of an aide for personal care or management needs?
Yes, 1:1 aide
Yes, shared
No
I understand that C-HOPE cannot provide assistance for personal care needs such as toileting and eating.
Did/does the applicant have a Behavior Intervention Plan (BIP)?
Yes
No
How does the applicant communicate? Check all that apply.
Verbal - carries on full conversations. Are there articulation challenges?
Verbal - carries on limited conversations. Articulation challenges?
Echolalia (repeats words and/or phrases)
Sign Language (ASL or Signed Exact English)
Gestures (other than sign language)
Augmentative/Assistive Technology - high tech
Augmentative/Assistive Technology - low tech
Others
Please indicate
Which best describes the applicant's physical abilities?
Ambulatory
Ambulatory with assistance
Wheelchair user
Does the applicant have any allergies? (e.g., medication, food, bee stings, latex, etc.)
Yes
No
If yes, please provide detail
Is an EpiPen required for any allergy?
Yes
No
If yes, please provide detail
Please list any dietary restrictions the applicant may have.
In the event of a serious emergency (e.g., fire), what is the most critical piece of information about the applicant do you want us to share with first responders?
Is the applicant fearful of or adverse to any of the following? Check all that apply and provide detail.
Loud noises
Animals/Insects
Textures
Siren/Fire Alarm
Police/Firefighter/EMT/Paramedic
Other
None of the above
Please indicate
Do any of the following frustrate the applicant? Check all that apply and provide detail, as necessary.
Noise
Raised voices
Touch/Touching
Bright lights
Cold temperature
Hot temperature
Other
None of the above
Please indicate
Are there any key words, phrases, or other stimuli that should or should not be used with or around the applicant?
Please list requested accommodations. C-HOPE willl consider requests as program limitations allow.
Please list interests and hobbies of the applicant.
In order to maximize the applicant's experience in this program, please provide additional information that would be valuable for C-HOPE staff to know.
PARENT / GUARDIAN INFORMATION
Name
(Required)
First
Last
Address
(Required)
Street Address
City
State / Province / Region
ZIP / Postal Code
EMERGENCY CONTACT INFORMATION
Contact #1
Name
(Required)
First
Last
Relationship to the applicant
Cellphone
(Required)
Home Phone
Permission
I give permission to Contact #1 to pick up applicant
Contact #2
Name
(Required)
First
Last
Relationship to the applicant
Cellphone
(Required)
Home Phone
Permission
I give permission to Contact #1 to pick up applicant
Please be sure to include the following with your application:
Program application
$25 non-refundable deposit (checks payable to C-HOPE Inc.)
Consent/Release forms
Medication self-carry/administer documentation, if applicable
Phone
This field is for validation purposes and should be left unchanged.
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